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Homelessness and Health

Homelessness and Health

Homelessness and Health

Mr. James was cold. An internal body temperature of 84.2 degrees Fahrenheit qualifies as severe hypothermia. When I first met him in the Emergency Department, his grey hair was poking out from under a warming blanket. Warm fluids were running through an IV into his veins and through a catheter into his bladder. He responded incoherently when I asked his name. His 67-year-old brain and body had frozen.

I ordered a battery of blood tests searching for the cause of Mr. James’ hypothermia. As I’d been taught in medical school, I considered infection, hypothyroidism, adrenal insufficiency, and carbon monoxide intoxication. All the tests came back normal. 

It turns out Mr. James was cold from sleeping outside. Someone stole his blankets and the temperature dropped, a simple formula for hypothermia. He’d had three identical hospital admissions in the last year, each of which involved the same process: We warmed him up, gave him a few hot meals and a warm bed for the night, and then discharged him to the street with a taxi voucher to a homeless shelter. He walked out of the hospital and right back into the cold.

Discharged to the Street

As a resident, or doctor in training, one of my key roles is coordinating discharges from the hospital. Every time I sign a discharge order, I must select the patient’s destination from a dropdown menu of options including home and other levels of care such as skilled nursing facility. “Street” is not an option and yet this is where patients like Mr. James end up. 

Some patients are lucky and end up finding accommodation at Medical Respite in San Francisco. Since 2007, Medical Respite has provided 45 beds to homeless individuals in need of continued recuperation after hospital discharge. Patients at Medical Respite receive nursing and wound care and help with medications, in addition to shelter, food, and space to elevate healing limbs or refrigerate medications. But beds at Medical Respite are in high demand and they get more referrals than they can accept. 

Working Toward a Solution

You don’t need to go to medical school to understand that discharging to the street is bad for health. The California State Legislature just passed Senate Bill 1152 by Dr. Ed Hernandez that proposes a solution to connect patients to the services they need. Sponsored by CPEHN and SEIU, Senate Bill 1152 would make sure that hospitals are doing everything they can connect homeless patients to a social services agency or provider, such as a homeless shelter, that has agreed to accept the patient.  

I support Senate Bill 1152 as part of a much larger solution needed to care for our most vulnerable patients. While hospitals must do their part to ensure the health of patients beyond short inpatient stays, they cannot be held solely accountable for a broader lack of social services such as affordable housing. More discharge options such as Medical Respite need to be made available in order to enable hospitals and their care teams to ensure safe discharge plans for patients.

The Cost of Poor Health

Study after study has shown that the United States has worse health outcomes than many other developed countries, despite spending more on health care.  Why? The simple reason is that it takes more than health care to make a country healthy. A 2016 RAND corporation study showed that the United States spends a higher percentage of its GDP on medical care than other countries, but when the percentage is combined with money spent on social services, the United States falls behind. If there is not equal—if not greater—consideration for affordable housing, nutritional assistance, education, mental health and addiction services and other key social service, spending on health care, even with cutting-edge technology, inevitably leads to higher costs and poorer health outcomes.

Taking Action

Looking back on my first year as a doctor, I feel proud of how much I have grown as a physician and a person. I am warmed to think of the specific people that I have positively impacted. But I also feel disheartened that I have been nothing more than a cog in a machine for many others who will continue to come through the revolving hospital door with the same afflictions that I have already transiently treated. While I will continue to take seriously my obligation to care for any patient, regardless of race, ethnicity, sexual orientation, immigration status, or ability to pay, it is now clear to me that many patients do not need modern medicine. 

We doctors can often only bandage deeper wounds until it is widely recognized that the foundation of good health lies in our communities and social structures. Meeting this challenges means everyone needs to come to the table and do their part, including hospitals. This starts with treating the most vulnerable among us with compassion, dignity and respect. Senate Bill 1152 (Hernandez) does just that. I ask you all in joining me to urge Governor Brown to sign this bill into law.

- Grace Hunter MD MBA

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